407

addition 7 suspected cases. These figures are perhaps belowthe truth, bat there is no good reason for supposing thatthey are greatly below. Constantinople was declared a

"clean " port on Oct. 2nd, and the cases which occurredlater being regarded as sporadic only the port was notdeclared reinfected. A few cases of cholera recentlyoccurred at Silivri, on the shores of the Marmara, and also atRodosto, on the same coast.

Claolercc in Smyrna.The following figures are in continuation of those com-

municated in my previous letter :-

The last case of cholera in Smyrna was registered on Oct. 8th.In all, 293 cases and 179 deaths were recorded.

Cholera among Returning Troops and Emagrccnts.Troops and released prisoners of war have recently been

returning in large numbers to Turkish ports. I referred in

my previous letter to the occurrence of cases of cholera andthe detection of germ carriers among troops arriving atthe lazarets of Kavak and Clazomene (near Smyrna).Recently the numbers of cholera cases and of carriers havediminished. A few certain or suspected cases have beenseen in troops arriving in Trebizond, and from time to timereports are received of the detection of germ carriers in theSmyrna lazaret. Both troops and emigrants-mostly fromSalonica-have been arriving in the latter lazaret in veryovercrowded steamers, and there is said also to have been aconsiderable amount of "sanitary contraband "-that is tosay, many emigrants are said to have proceeded from Salonicaor elsewhere to some of the Ægean islands in Greek occupa-tion, whence they made their way to Smyrna or some otherplace on the mainland without undergoing any quarantineor other sanitary measures. In Salonica itself no cases ofcholera were seen after the end of September.

Cholera in Roumenica.The following official figures have now become available

respecting the outbreak of cholera in Roumania :-

These are the latest figures received here; they show that the epidemic has been one of considerable severity, takenas a whole, but an examination of the bulletins shows thatthe disease was widely spread over the country. Thus thelatest bulletin contains the names of 22 infected districts,containing no less than 113 infected "communes." Thecommunes returning the highest figures have been those ofTeleorman, Romanati, Doljie, and Talomita. Many of thecases seem to have occurred among the troops during therecent mobilisation and demobilisation of the Roumanianarmy.

Cholera in Russia.There has recently been a considerable extension of the

outbreak of cholera in Russia, the beginning of which wasmentioned in my previous letter. The disease first appearedin Kherson on August 13/26th. Early in September caseswere reported from Nikolaieff, in the Odessa district, and animported case (from Kherson) was seen at Zvenigorod, in theRief government. Later the infection spread to the districtsof Kherson, Odessa, and Elizavetgrad, in the government ofKherson ; to those of Dneprovsk and Aleshki, in the govern-ment of the Taurida ; to those of Ismailia and Akkerman; inthe government of Bessarabia ; to those of Nikopol andEkaterinoslav, in the government of Ekaterinoslav ; and tothe town of Poltava. The latest bulletin published showsthat down to the 5/18th of October 213 cases of the disease,with 85 deaths, had been registered in the various infecteddistricts.

Cholera in the Austrian Empire,Cholera has been prevalent in sporadic-almost in epi-

demic-form during recent months in many parts of Austria,Hungary, Croatia-Slavonia, and Bosnia-Herzegovina. In

Austria 25 cases in all with 13 deaths were recorded down to-the end of September, when the disease disappeared. Ofthese the larger number-21 cases with 11 deaths-occurredin Galicia ; a single case and death were seen in Dalmatia,1 case in Lower Austria, and 2 cases with 1 death inBohemia. These cases included 1 imported to Vienna onAugust 26th in a person arriving there from Salonica byway of Budapest. In Hungary the returns officially publishedhave been as follows :—

The above cases and deaths were distributed over the"comitats" of Bacs-Bodrog, Bereg, Temes, Kras,4o-Sz8r6ny,Torontal, Ung, Pisti-Pilisu Solt Kiskun, Zemplen, Zala,Borsod, and Fejer.From Croatia-Slavonia the earlier returns are imperfect.

but the following bulletins have been received here :-

The bulletins contain the names of over a score of infectedcentres situated mainly in the " comitat " of Srijem, but also,in those of Virvoitica and Pozega.From Bosnia-Herzegovina no periodic returns have been

received, but a very considerable number of both cases anddeaths have been reported from a dozen or more infectedcentres, situated in the districts of Tuzla, Brcko, Bijeljina,-Zvornik, Gracanica, and others.Constantinople, Jan. 15th, 1914.

ROYAL COMMISSION ON VENEREALDISEASES.

AT the eleventh meeting of the Royal Commission held onJan. 19th evidence was given by Lieutenant-Colonel T. W.Gibbard, R.A.M.C., head of the Rochester Row RoyalMilitary Hospital.

Colonel Gibbard said that the most important causes ofthe decrease of venereal diseases in the army were theimproved treatment and the instruction of the men bylectures and individual talks; other causes contributing to-the reduction were greater temperance, the increasedattractions of barracks, and the greater encouragement givento sports and outdoor games. The problem of the pevention of

t the spread of venereal diseases in the civil population could1 best be attacked by providing early diagnosis and treat-t ment, by enlightening the public regarding the diseases by

lectures and otherwise, and by promoting temperance. As.’ syphilis was chiefly spread during the early stages of the

disease, early diagnosis and treatment were of the greatestimportance, especially now that the methods of diagnosis-were so good and that by the use of salvarsan a patient was.rendered non-infective in from 24 to 48 hours. For the-

provision of early diagnosis it was necessary that arrange-ments should be made whereby microscopic examinations-and blood tests could be carried out free of charge to private

e practitioners or patients.s With regard to treatment Colonel Gibbard was of opiniond that special hospitals for venereal diseases were nots to be recommended ; every general hospital should provide a

certain number of beds for the treatment of the diseases, ande these beds should be in general wards. An out-patients’s department should also be organised so as to give patients

every facility for early diagnosis and treatment; and theL- department (which should not be called venereal) should be1 kept open at hours suitable to the working classes. Colonel,d Gibbard thought that compulsory notification was mosto undesirable as it would lead to concealment of the disease.s On the subject of education respecting venereal diseases he:, thought that there would be advantage in lectures being

given at all large factories by selected medical men (orwomen where the employees were women), and that theselectures might perhaps be illustrated by kinemacolour photo-

i- graphs. At the lectures great stress should be laid on the-importance of seeking medical advice on the first suspicion

n of the disease and of not consulting chemists or quacks.

408

The experience at Rochester Row had shown that much goodmight be done in this direction. The number of secondarycases among the men reporting sick at that hospital hadbeen reduced until it was now only equal to the number ofprimary cases, whereas for the army generally it had beenfound that for every soldier commencing treatment in theprimary stage five began in the secondary stage. Theimportance of this reduction was illustrated in the results ofthe treatment of 62 consecutive cases of primary syphilisduring the last 18 months, which have been under observa-tion for periods varying from 6 to 9 months from the com-pletion of treatment. None of these cases- have developedsecondary symptoms, only one case relapsed, and that wasprobably a reinfection.

Colonel Gibbard gave an account of the methods oftreatment employed at Rochester Row and of the resultsobtained. The use of a combined treatment of mercury andsalvarsan had effected a reduction in the average number of

days in hospital on first admission from 42 to 23’ 2, while thepercentage of relapses had fallen from 33 with mercury aloneto 3’ 9 per cent. with the combined treatment.

Questioned respecting some remarks which had been

recently published regarding the dangers attending the useof salvarsan, Colonel Gibbard said that all his experiencehad gone to show that, provided the medical man using ithad acquired and knew thoroughly the technique and contra-indications, salvarsan could be safely used, and in con-

junction with mercury was the most effective cure known.At Rochester Row they had had no deaths or ill-effects

following its use, and they had given more than 3000intravenous salvarsan injections.

THE ANNUAL REPORT OF THE MEDICALOFFICER OF THE LOCAL GOVERNMENT

BOARD FOR 1912-13.

IL1

Statistics of Tuberculosis.Dr. Newsholme devotes a considerable portion of his

report to the statistics of tuberculosis and to the difficultiesencountered in interpreting the figures available. The dutyto notify pulmonary tuberculosis in all classes of practiceand in the whole of England and Wales-was imposed on andafter Jan. 1st, 1912, and apparently the total number ofcases notified during that year was 110,706-viz., 33,392 inLondon, 72,193 in the rest of England, 4966 in Wales andMonmouth, and 155 in ports. In the first quarter of 1913the notified cases of pulmonary tuberculosis are stated tohave been 30,788, and from Feb. lst, when other forms oftuberculosis were also notifiable, the reported number ofthese cases was 15,214. The proportion between notifica-tions of and deaths from pulmonary tuberculosis varies

greatly in different parts of the country and in different

parts of the same administrative area. Provisionally the reportrecommends that" the medical officer of health of a districtin which the notifications of phthisis do not number morethan twice the deaths from this disease may considerwhether in his area there is not failure to notify, andwhether the local administrative arrangements for thecontrol of tuberculosis are such as to ensure the confidenceof the local medical practitioners and patients." Animmediate increase of notifications may be secured byfacilitating the examination of sputum, and the desirabilityof greater public provision for this is urged in the report.Dr. Newshoime deprecates comparisons between districts asto phthisis which are based on the new notification returns,and considers that for the present death-rates furnish ourmost satisfactory means for determining the local incidenceof tuberculosis. In regard to deaths from tuberculosis in allurban areas with a population over 20,000 and in theaggregates of urban and rural areas in each county it hasbeen arranged that more detailed figures than those in theannual reports of the Registrar-General will be furnished bythe General Register Office to the Local Government Boardwith a view to investigations by the medical inspectors ofthe department where necessary.

1 The first part of this article appeared on pp. 339-341 of lastweek’s issue.

Tables are included in the volume which give the crudeand standardised death-rates from pulmonary and otherforms of tuberculosis, amongst males and females respectively.in the several administrative counties, county boroughs, andmetropolitan boroughs. Two phthisis maps

" for 1911 arealso given, in which some of these administrative areas areshown, shaded according to the intensity of the phthisismortality-rate, one map relating to males, the other tofemales. In the counties heavy relative incidence of phthisisappears from both maps to be characteristic of the westernand northern parts of Wales, particularly Cardiganshire, andof Cornwall. Among the county boroughs striking differencesin rates are brought out. Thus, per 1000 living at all ages,the male phthisis death-rates in Liverpool (2 26), :Manchester(2 0), Southampton (1 98), and Bournemouth (1 84) may becontrasted with those of Portsmouth (1-01), Huddersfield

(0 94), Devonport (0 73), and Wigan (0 71). Although thefigures are" corrected

" to bring the male and female popula-tions of the several towns to a common standard, the femalerates through all the tables are frequently very dissimilar to themale rates. The corrected female rate in Manchester, forexample, is only 1 08, while that of Devonport is 1.47. Dr.Newsholme frequently recurs in his report to the greatinfluence of migration on local figures, and urges that com-parison of death-rates from tuberculosis in the same areafor a series of years has greater value than comparison ofdistricts one with another.

In all the administrative areas except the rural districtsthe Registrar-General’s figures show that the male phthisisdeath-rate is much higher than the corresponding femaledeath-rate, and it is noteworthy that, while the male rate inLondon is nearly double that in the rural areas, the excessis only 18 per cent. in the case of females. In discussingthis question and the curves of phthisis death-rates atdifferent ages among males and females Dr. Newsholmeobserves that urban conditions evidently do not imply thesame excess of phthisis for women as for men, or, to adoptanother method of statement, that influences operate inrural districts, so far as women are concerned, which preventthem from benefiting from the more favourable general con-ditions of rural life-influences probably arising in con-

nexion with the housing of the healthy and the sick. The

age incidence of the maximum phthisis death-rate in bothsexes is earlier in life in the rural districts than in the towns,a fact which may be regarded as due in part to migratorymovements of consumptive patients, and in part to the factthat in rural districts preventive measures against tuber-culosis, including housing improvements, have been less thanin the towns. Dr. Newsholme looks to the new tuberculosis

organisation, and the accurate recording of the antecedentmedical history of each tuberculous person rendered possibleby it, to enable the influence of migration and of other con-ditions which affect the local incidence of phthisis on age andsex, to be more accurately measured in future.

Administrati,z,e Control of Tuberculosis.Part III. of the annual report of the Local Government

Board for 1912-13 2 contained the summary of the importantadministrative work carried out during that year in regard totuberculosis, but the present report supplements this state-ment by much useful information, and the various circularsand orders issued by the Local Government Board duringthe period are included in the volume. After describing newprinciples introduced by the last notification of tuberculosisorder and its consolidating effect, Dr. Newsholme refers to

public health action following notification, and the dutieswhich have been placed on medical officers of health in thematter of making inquiries into notified cases. Hitherto themedical officer of health has been handicapped, except in afew places, by the difficulty of securing expert aid in

examining contacts, and has been obliged to carry out thisinvestigation more or less imperfectly. Under the newconditions it is hoped that throughout the country theservices of the tuberculosis officers will be available forthe work, and the report suggests that outside the

county boroughs the tuberculosis officer and tuberculosisnurses, who are appointed by the county authority.should be appointed also as officers of the various districtcouncils and sanitary authorities, possibly at a nominalsalary, in order to make their position in the matter regularand enable them to act for the district medical officer of

2 THE LANCET, Jan. 3rd, 1914, p. 45.